Weaving Medication into a Medical Weight Management Plan

Weight loss medications are often in the news, om social media, and the topic of many conversations outside the medical atmosphere. There are headlines and everyone is wondering, is this the end to the obesity epidemic? If so, is that “good” from a health perspective? Has medical science finally found an answer? Let’s take a step back for some perspective.

Tirzepatide is the first in a new class of medications known as “GLP-1/GIP receptor agonists” and the latest that is FDA approved to treat obesity. However, there are two related medications already FDA approved to treat obesity that do some of what Tirzepatide does as they are “GLP-1 receptor agonists.” These medications have been FDA approved for Type 2 Diabetes and/or obesity since 2004 and also do show weight loss as long as you use them. Liraglutide (Saxenda) was approved in 2014 for chronic weight management. Semaglutide (Wegovy) was approved for chronic weight management in 2021. An unrelated, but highly effective medication, Qsymia, was approved for chronic weight management in 2012. These medications did not “end” the obesity epidemic, so will semaglutide and tirzepatide be any different?

For these medicines to work, people need to be able to get them. Currently, weight management medications is not a default benefit and most employers do not “opt in,”. So, most people have coverage excluded regardless of medical conditions associated with excess weight. The second main difference is the amount of weight loss. Saxenda shows an average of about 8% weight loss. Wegovy shows an average weight loss of 15%. Mounjaro shows an average weight loss of 15% in people with Type 2 Diabetes, but 20% in people without Diabetes. Now, it has not been out for long enough for people to have even taken it for a year, but I have seen that it seems “stronger” even initially. For a small number of people, this means it is not tolerable because of nausea, dehydration, or abdominal pain. I counsel people when I prescribe it that they need to eat as if they had bariatric surgery or they may throw up: in very small amounts. This can be a problem for some people if they go out for a special meal and the medication is in their system.

So, is this a “good” thing to have this medication out and available and highly effective and being given away by the manufacturer and going viral on Tik Tok? The pharmaceutical companies would say that we are finally appropriately treating obesity as a disease and that employers and insurance companies need to do the right thing and start covering these medications and paying for them at the cost of about $1000 a month, for the approximate 47% of the population that meets the criteria for their use. Economics aside, as that is outside the scope of my expertise, is this “good” from a medical/health perspective?

The considerations I think are crucial to keep in the forefront of the conversation are:

• 25% of the weight lost, on average, was lean body mass, in the studies. This is fine if you have “extra” lean body mass to lose, but, if you do not, then losing lean body mass can cause or be associated with other negative health effects such as osteoporosis, hypogonadism (low sex hormones), frailty, fragility and perhaps increased risk of death in older age,

• Studies show that weight recurrence happens in the year after this medication is stopped. While this does not mean that people should not use it, it has implications and is important to plan for. Separate studies and guidelines have shown that weight cycling (losing weight and gaining it back repeatedly) is bad. So, a comprehensive treatment plan and discussion needs to include a plan for this fact about these medications. But, in general, the studies show that a person should expect to either take the medication long term or have weight recurrence if stopped after about a year

• Weight loss achieved through these medications does not improve physical fitness. That is achieved only through consistent exercise of the proper intensity and volume. It is very true that for many people, weight loss needs to happen before exercise due to various factors like pain or shortness of breath. But, exercise is important for health regardless of weight or size, when possible.

• Quality of nutrition matters. While it is true that body weight does matter for health, even if a person is “healthy”, the converse is true; quality of nutrition matters at a lower weight also. Studies have shown that a Mediterranean type diet is the “healthiest” diet pattern overall. While it may not be superior to others or to medication for weight loss, eating “healthy” makes a difference whether a person is losing weight or not.

• Most crucially, a historical perspective on obesity shows that the number of people with obesity and the severity of obesity has significantly worsened over the last 30 years. This table shows that the number of people with obesity in the country has more than doubled to 35% in the last 30 years. A notable study predicts that number will reach 50% by 2030 and be over 50% in some states. So, we have our head in the sand if we think that the need for a medication is the only need here and that a medication will solve the issues of our obesogenic society that seems to be getting worse for all groups of society, but more so for those of lower socio-economic status, adding another gap and further demonstrating the role of environment and societal factors.

What is the right answer? My fantasy would be:

• Re-engineer society to be pro-health instead of obesogenic

• Assess the individual: some people benefit from medication right away and others may benefit from other interventions first with a reassessment

• Bridge the remaining gaps with the best that science and medicine has to offer while engaging in shared decision making.

How do we achieve this seemingly impossible goal? Like any other, we all take the first step, work together, and keep going. We are in different boats, but we are all in a storm togethre.

Take Back Your Society,

Valerie Hope-Slocum Sutherland, MD

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